Nursing Intervention: Prioritizing and Addressing Health Issues

This assignment presents a nursing intervention case study focusing on a 69-year-old patient, Jim Cooper, admitted with multiple health issues. The student identifies five key health concerns: impaired gas exchange, ineffective airway clearance, dehydration leading to fluid volume deficit, alcohol withdrawal, and risk of depression. The assignment prioritizes three of these issues: ineffective airway clearance, impaired gas exchange, and dehydration. The student provides detailed rationales for the prioritization, supported by current literature, and outlines specific nursing interventions for each prioritized health issue, including airway management, oxygen therapy, fluid balance, and patient education. The interventions encompass assessments, monitoring, and therapeutic actions to improve patient outcomes.

Running Head: NURSING INTERVENTION
Nursing Intervention
Name of the Student:
Name of the University:
Author’s note:

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1. Five health issues identified:
The given case study is about Jim Cooper, a 69 year old adult. The five health issues
identified in Jim includes:
1. Impaired gas exchange
2. Ineffective airway clearance
3. Dehydration leading to fluid volume deficit (FVD)
4. Alcohol withdrawal
5. He has a risk of depression due to loneliness.
The identified health concerns of Jim are mentioned of which three highest priority health
issues include
1. Ineffective airway clearance
2. Impaired gas exchange
3. Dehydration leading to fluid volume deficit (FVD)
2. Three highest priority health issue:
Ineffective airway clearance can be defined as the health condition involving
complications in maintaining a clear airway. It is the inability of the system to clear
secretions or obstructions from the respiratory tract (Pascoal et al., 2016). The maintenance of
a clear airway is indeed a critical factor to life. It is characterized by abnormal breath sounds,
abnormal respiratory rate, rhythm and depth, dyspnea, excessive secretions, hypoxemia,
inability to remove airway secretions, absent cough and orthopnoea (Hooper et al., 2015) (de
Sousa, Lopes and da Silva, 2015). Sputum contains lower respiratory tract secretions,
oropharyngeal as well as the nasopharyngeal materials, microorganisms and the cells as well.
Mucous hypersecretion and impaired airway clearance as well as abnormal amount of airway

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secretion negatively impacts the pulmonary function reduces the defence system of the lung.
All these physiological changes elevate the risk of lung infection and progress to neoplasia.
Extensive damage of the cilia followed by hypersecretion of mucus poses a threat if the
airflow dependant mucus clearance is impaired and it is important for maintenance of the
airway hygiene as well.
Impaired gas exchange is defined as excess or deficit in the oxygen or carbon dioxide
elimination at the alveolar-capillary membrane. At the alveolar capillary membrane surface
the diffusion of the prime respiratory gases, carbon dioxide and oxygen occur exploiting the
concentration differences between them. The difference in the concentration is maintained by
the ventilation occurring in the alveoli and perfusion of the pulmonary capillaries. This
balance when disrupted causes impaired gas exchange. This can also cause the alveoli to
collapse. It causes collapse of the alveoli and impaired ventilation (Castellan et al., 2016). It
impacts the oxygenation of the tissues which is indeed a vital function for living. This is a
symptom associated with respiratory disorders linked with impaired airways (Hooper et al.,
2014). It is also related to acute respiratory infection that negatively impacts the functionality
of the respiratory system and contributes to the signs and symptoms of the onset of the same.
If left untreated it can lead to pulmonary edema, pneumonia, atelectasis and acute respiratory
distress syndrome (Pascoal et al., 2016).
Dehydration leading to fluid volume deficit (FVD) is the third health priority issue
identified. Fluid volume deficit is also termed as hypovolemia that is excessive loss of the
extracellular fluid from the body (Marra et al., 2016). This syndrome is observed as a result
of the depletion of the total sodium content in the body. This extracellular fluid constitutes
almost 20% of the body weight of the individual and exploits the blood plasma, spinal cord
fluid, fluid in between cells and lymph. It is a health compromised condition where the rate of
fluid output exceeds the rate of fluid intake (Begg, 2017). The consequences of the fluid

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volume deficit may lead to decreased circulating blood volume, low amount of venous return,
and may be at the risk of arterial hypotension. This can pose a threat of myocardial failure
due to the elevated demand of the myocardial oxygen and the low rate of tissue perfusion.
This promotes anaerobic respiration that can cause acidosis. All the cumulative health
compromised state may result in multiple organ failure.
3. Nursing intervention:
Nursing interventions for Ineffective Airway Clearance
It is the duty to educate the patient regarding the proper ways to cough and breathe which
involves coughing two to three times in succession and taking deep breath (Hooper et al.,
2014). They should also be taught about the optimal positioning, exploit hand splints or
pillows when coughing, exploit the huff and quad techniques. They should promote the usage
of spirometer as well as the advantages of frequent changes in position (Taffet, Donohue and
Altman, 2014). The most efficient method to remove secretions from airway is by coughing.
Deep breathing ensures sufficient oxygenation before controlled coughing. If coughing is
ineffective the patient should resort to naso-tracheal suctioning because suctioning is
effective in patients who are unable to cough out secretions due to weakness, excessive
tenacious mucus secretions as well as thick mucus plugs (Hooper et al., 2015). The nurse
should exploit soft well-lubricated curved-tip catheters. Such catheters are efficient in
removal of secretion from a specific side of the lung. Well- lubricated catheters prevent
trauma on the mucous membrane and reduces irritation (de Araújo, de Carvalho and Chianca,
2014). The nurse should provide oxygen supplement if required and the required medications
that involves mucolytic agents, bronchodilators, expectorants that ensure clearance of the
airway. The nurse should provide oral care in an interval of 4 hours. The care giver should
note the heart rate, blood pressure and the temperature of the patient as elevated rate of
breathing impacts the hypertension and promotes tachycardia (Doenges, Moorhouse and

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Murr, 2014). The colour, amount, quality, consistency and the odour of the sputum. This
gives the indication of laboured breathing and the appropriate treatment for the cause. The
nurse should exploit the use of oximetry to monitor the oxygen saturation as well as the
arterial blood gases. The oxygen saturation should be maintained at 90% or greater.
Abnormality in the arterial blood gases causes elevated pulmonary secretions as well as
respiratory fatigue (Haykowsky et al., 2013).
Nursing intervention in impaired gas exchange
The nurse should assess the respiratory rate, depth and effort as well as assess the
abnormal breathing patterns. The nurse should monitor the behaviour and mental state of the
patient and check for the symptoms of restlessness, agitation, confusion and lethargy. This is
because chronic hypoxia impacts the cognition and the mentioned symptoms are observed I
case of impaired gas exchange (Haykowsky et al., 2013). The nurse should monitor the heart
beat and the blood pressure of the patient. This is because hypoxia may result in the medical
emergency of the patient due to cyanosis. Patients suffering from dizziness, headaches,
disorientation and reduced ability to follow instruction is due to the medical symptom of
hypercapnia. The care giver should exploit the use of pulse oximeter to detect the changes in
the level of oxygenation (de Araújo, de Carvalho and Chianca, 2014). The nurse to check the
nutritional condition and the hydration level of the patient and check the level of
haemoglobin. Low haemoglobin shows that there is reduced uptake of oxygen at the alveolar
level and hence there is decreased level of oxygenation in the tissues. The nurse should
monitor the ability of the patient to cough. If possible they should encourage the patient for a
chest X-ray as the chest x-ray would lead to determination of the etiological factors of the
impaired gas exchange (de Sousa, Lopes and da Silva, 2015). The nurse should position the
patient in a semi-Fowler’s position and monitor that they should not slump down in the bed.
This semi-Fowler’s position ensures increased thoracic capacity, total descent of the

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diaphragm and elevated level of lung expansion (Pascoal et al., 2016). The patient should
change their position every 2 hours and monitor the venous oxygen saturation post the
turning. If the saturation level fails to return back to the baseline the patient should be turned
back to the supine position and the oxygen status should be monitored again. This is to ensure
prevention of the complications regarding immobility. The nurse should avoid the condition
of elevated concentration of oxygen in case of patients with COPD (Castellan et al., 2016).
Nursing intervention in dehydration causing fluid volume deficit (FVD)
The nurse should monitor the heart rate and the blood pressure of the patient because
decreased blood volume promotes tachycardia and hypotension. In case of electrolyte
imbalance the pulse rate is weakened. The changes in blood pressure also aids in detecting
the orthostatic changes. A 20mm drop in the systolic blood pressure and a 10mm drop in the
diastolic blood pressure indicates a decreased circulating blood volume (Marra et al., 2016).
The skin turgor and oral mucous membranes should be assessed as vital signs for
dehydration. The colour and amount of urine should also be assessed and it should be less
than 30ml/hour for 2 hours consecutively, analysis of serum electrolytes and osmolality
should also be executed (Begg, 2017). The nurse should monitor the fluid status with respect
to the dietary intake of the patient. The nurse should monitor the presence of symptoms like
nausea, fever and vomiting. The symptoms of circulatory overload that exhibits tachypea,
headache, flushed skin and increased central venous pressure should be closely monitored
which can efficaciously decrease the complications associated with the fluid replacement.
The care provider should urge the patient to drink the prescribed amount of fluid. Oral fluid
replacement is a cost effective intervention to combat this health issue. The nurse should
emphasize on the importance of oral hygiene. Promoting mouth care enhances the interest in
drinking and decreases the discomfort of the dry mucous membrane (Hooper et al., 2014).

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Reference
Begg, D.P., 2017. Disturbances of thirst and fluid balance associated with aging. Physiology
& behavior, 178, pp.28-34.
Castellan, C., Sluga, S., Spina, E. and Sanson, G., 2016. Nursing diagnoses, outcomes and
interventions as measures of patient complexity and nursing care requirement in Intensive
Care Unit. Journal of advanced nursing, 72(6), pp.1273-1286.
de Araújo, D.D., de Carvalho, R.L.R. and Chianca, T.C.M., 2014. Nursing diagnoses
identified in records of hospitalized elderly. Investigacion y educacion en enfermeria, 32(2),
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de Sousa, V.E.C., Lopes, M.V.D.O. and da Silva, V.M., 2015. Systematic review and meta‐
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